PROVIDER MANUAL - Parkview Health Laboratory

PROVIDER MANUAL
Page 1 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Table of Contents
Introduction……………………………………………………………………………3
General Information………………………………………………………………4
Who Do I Call?……………………………………………………………………….5
ID Card Logo………………………………………………………………………….6
Credentialing………………………………………………………………………….7
Provider Changes…………………………………………………………………..8
Referral and Authorization…………………………………………………….9
Claims Payment
Filing……………………………………………………………………………….9
Key Information on Filing ………………………………………….10
Filing Period………………………………………………………………….11
Claims Payment……………………………………………………………11
Submission Guidelines
AS Modifier……………………………………………………………………12
Locum Tenen Physicians………………………………………………12
Anesthesia…………………………………………………………………….12
Page 2 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Introduction
Signature Care maintains a complete preferred provider network of
qualified medical professionals to meet the diverse needs of our
customers. We are pleased to have you in our network of providers.
In 1992, Parkview Health established the Signature Care PPO
network to meet the needs of northeast Indiana health plan
sponsors. Employees wanted convenient access to quality providers,
while employers sought favorable pricing for their healthcare claims.
Although these fundamental needs have not diminished, Signature
Care has continuously improved its new products and services and
expanded its coverage area. Today, throughout Indiana and
northwest Ohio, more than 95 hospitals, 11,000 providers and close
to 1,000 ancillary providers are contracted with Signature Care to
offer primary and specialty healthcare services.
This manual was established to assist our providers in efficiently
serving our members. While we hope we have answered most of
your questions, we do understand that other questions or concerns
may arise; we encourage you to contact us directly. You can reach
Provider Services by phone at (260) 373-9080 or 800-666-4449 or
by e-mail at ProviderServices@parkview.com.
Page 3 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
General Information
Signature Care is a statewide network of healthcare providers located in
Indiana and northwest Ohio that can be accessed through an employer’s
self-funded group health plan or a fully-insured carrier. Signature Care is
a Preferred Provider Organization (PPO). When an employer chooses
Signature Care as its PPO network, health plan participants receive
medical services at a negotiated rate from contracted providers.
Signature Care is neither an insurance company nor a provider, but a
network of contracted providers working in conjunction with an
employer’s health plan. Because we are not an insurance company, it is
important to define our services to our providers.
Parkview Health Plan Services (HPS) administers the Signature Care
network by credentialing providers, establishing contractual relationships
with physicians, facilities and PHOs, establishing fee schedules and
repricing claims. Only hospitals, physicians and healthcare providers who
have met credentialing standards are contracted to participate in the PPO
network.
An employer group’s plan and benefit design are established by the
employer and/or third party administrator's (TPA) or insurance company.
Therefore, to obtain benefits for a patient, other than Parkview
employees, you will need to contact the payor, not Signature Care. The
third party administrator will produce ID cards, assist employer in
designing benefit plans, assist providers with benefits and pay claims.
The Signature Care logo will always be identified on the member’s ID card
in addition to phone numbers for benefits, eligibility and Utilization
Review.
Page 4 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Who Do I Call?
For claim issues, verifying benefits, checking eligibility and Medical
Management questions, refer to the back of the member’s ID card for the
appropriate numbers. In most cases, providers will need to contact the
member’s TPA for this information. If questions need to be directed to
Health Plan Services (HPS) staff, please call:
HPS Customer Service
Phone: (260) 373-9100 or 1-800-666-4449
Fax: (260) 373-9004
HPS Provider Services
Phone: (260) 373-9080 or 1-800-666-4449
Fax: (260) 373-9003
HPS Medical Management
Phone: (260) 373-9030 or 1-800-666-6668
Fax: (260) 373-9040
Website
www.SignatureCarePPO.com
www.ParkviewTotalHealth.com
Page 5 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
ID Card Logo
Signature Care EPO
This product offers strong steerage to in-network providers. Signature
Care EPO has very strong steerage to incentivize members to not utilize
out of network services. All Signature Care guidelines will remain the
same for Signature Care EPO providers, e.g. claims sent to HPS for
repricing, with Customer Service and Provider Service performed by HPS
staff. Reimbursement is at the Signature Care contracted fee schedule.
Page 6 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Credentialing
Credentialing is the process that evaluates each physician, hospital,
facility and allied health provider. Each applicant has the responsibility of
producing timely and adequate information for a proper evaluation of
qualifications and for resolving any doubt about such qualifications. Each
participating provider must maintain compliance with all criteria in the
Credentialing Plan as a condition of continued participation.
All providers must be credentialed for Signature Care prior to contracting,
either through the HPS Credentials Committee or by delegated
credentialing entity such as a network or PHO. Hospital-based providers
(Emergency Room Physicians, Anesthesiologists, Radiologists and
Pathologists) are not required to be credentialed.
The credentialing process may be delegated by contract to another entity.
The HPS Credentials Committee will review the entity’s Credentialing Plan
to ensure compliance with HPS’ criteria, policies and procedures. The
HPS Credentials Committee must approve the delegated entity’s plan.
The delegated entity’s Credentials Committee must be constructed to
meet state and federal requirements for peer review.
Recredentialing
Recredentialing is conducted at least every two years. Review of ancillary
facilities will occur at least every three years.
Page 7 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Provider Changes
Timely notification of changes from providers within their organization is
requested. Please notify Provider Service as soon as possible with any of
the following changes:
New Practitioner
New Location
Termed Practitioner
Termed Location
Tax Identification Number
Phone Number
Fax Number
Address
All changes submitted to Signature Care must be in writing. Please
complete our Change Form and return to Provider Service representatives
by:
E-mail at ProviderServices@parkview.com
Fax at (260) 373-9003
Mail to:
Signature Care
Attention: Provider Services
PO Box 5548
Fort Wayne, IN 46895-5548
Page 8 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Referral and Authorization
Most payors have health benefit plans that include utilization
management programs. The payor selects the utilization management
organization. Health Plan Services performs utilization management for
many of the payors, however, it is important to check the back of the
Member’s ID card for the name and phone number of the utilization
organization contracted to provide these services. Failure to
communicate appropriately with the utilization management guidelines
may affect reimbursement.
Claims Payment
All Signature Care claims are to be submitted to Parkview Health Plan
Services (HPS), either electronically or on paper, for repricing.
Electronic Filing
Use TKSoftware: Payer ID is 35162
Use Emdeon: Payer ID is 35162
The provider must verify receipt
Parkview Health Plan Services has partnered with TKSoftware to offer
providers an efficient and less expensive direct electronic claim
submission option. Direct electronic claim submission on a standard 837
format to HPS through TKSoftware is free. If you wish to receive
information on TKSoftware, please contact Provider Services at (260)
373-9080 or by email at ProviderServices@parkview.com.
Paper Filing
Send to:
Parkview Health Plan Services (HPS)
PO Box 5548
Fort Wayne, IN 46895-5548
CMS1500 (formerly HCFA) – red and white form
Use black ink
Send claims flat with no staples
Page 9 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Paper Filing continued
Supporting documentation must have sufficient patient
identifying information
Documents will be scanned and must be readable by optical
character recognition (OCR) software
o Use Standard business fonts such as Arial or Times
Roman
o Do not artificially insert spaces between characters
within a word
Align information in the appropriate box
Do not hand write on claims
Key Information for Claims Filing
Insured/Subscriber’s full name and address
Insured/Subscriber’s social security number or member ID
number
Insured/Subscriber’s group plan number
Insured/Subscriber’s group number
Patient’s full name, date of birth and address
Dates and place of service
Valid ICD-9 codes for all diagnoses treated
Date/place/nature of occurrence if diagnosis is due to
accident/injury
Valid CPT codes for all services rendered
Valid HCPCS codes for any medical supplies or equipment
Valid revenue/CPT codes on UB-92 forms
Amount charged and quantity of services
Amount collected from the patient
Provider name, tax identification number and billing address
If a claim is submitted without the above information, it may be returned
to the provider for completion. Claims with corrections or alterations will
not be accepted.
Page 10 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
Filing Period
PPO repricing is subject to the payor filing guidelines.
Claims Payment
Network providers shall accept payment from Payors for covered services
in accordance with the reimbursement terms outlined in the Participation
Agreement. Payment made to providers constitutes payment in full by
payors for covered benefits except co-payments, co-insurance and
deductibles. Providers may not bill members for the balance of covered
services above the fee schedule reimbursement; however, a member can
be billed for non-covered services.
Providers will be reimbursed the fee schedule amount no later than thirty
(30) business days after the payor receives the clean claim. The payor is
required to pay, deny or provide notice within thirty (30) business days
from receipt of the claim. If the provider does not receive notice or
payment within this timeframe, the provider is entitled to full billed
charges and should seek payment from the payor. Provider may bill
member for services if the payor fails to pay.
For claims status, please contact the TPA or insurance company on the
group health plan identification card. If no card is available, call
Signature Care customer service at 800-666-4449 extension 39100.
Please have the date of service, name of patient and/or patient
identification number available at the time of the call.
Appeal Process
Participating Providers have the right to file a Complaint at any time for
any reason. Complaints regarding a claim dispute are to be directed to
the Payor.
Page 11 of 12 Last Revised December 2008

Parkview Signature Care
PROVIDER MANUAL
AS Modifier Claim Submission Guidelines
The use of the AS modifier appended to a surgery code indicates that a
midlevel practitioner is assisting at a surgery. It is the position of HPS,
and it’s Board of Directors, that the use of midlevels, such as physicians
assistants and nurse practitioners, in the operating room may create
efficiencies for the physician, however they are working incidental to the
primary surgeon. The primary surgeon is billing the global charge for the
surgery, and is being reimbursed accordingly.
Signature Care does not consider physician assistants and nurse
practitioners charges for assisting at surgery eligible for reimbursement.
Repricing sheets will reflect an allowable of zero. The service will be
considered a provider write-off and not patient liability.
Locum Tenen Physicians Claim Submission Guidelines
Signature Care will allow the use of a “temporary” or locum tenen
physician by a contracted Physician Group for a period of up to, but no
exceeding, ninety (90) days. The locum tenen physician will provide
coverage in a contracted physician’s absence for the following
circumstances, including but not limited to: illness, pregnancy, vacation,
continuing education, missionary trips or military duty. Should the locum
tenen physician’s tenure exceed ninety (90) days, he/she must be
credentialed (when applicable) and contracted.
The physician’s group will submit claim for the locum tenen services using
the contracted physician’s name in box 31 of the standard CMS1500
(formerly HCFA 1500) claim form. Modifier Q5 or Q6 should be appended
to the CPT code in box 24D of the CMS 1500 claim form to indicated
services were rendered by a locum tenen physician.
Anesthesia Claim Submission Guidelines
Page 12 of 12 Last Revised December 2008